Greater Boston Urology Blog

Prostate Cancer Treatment Options: Active Surveillance

This past May, The New York Times published an article titled "More Men with Prostate Cancer Are Choosing to Avoid Treatment." The article discusses "active surveillance," where men with early-stage prostate cancer forgo treatment and instead opt to regularly monitor their cancer to make sure it hasn't grown or spread.

The article states that more and more men are choosing this option: "national data from three independent sources consistently finds that 40 percent to 50 percent of them are making that choice."

But is active surveillance always the best choice? What are the pros and cons? And where do we, at Greater Boston Urology, stand on active surveillance? We'll answer these questions—and more—in the text that follows.

Active Surveillance: Who's Eligible?

Not every patient is eligible for active surveillance. In order to be eligible, the patient typically must… • Be in a very low-risk or low-risk category, which is defined as a Gleason score of 6 or less • Have two or fewer core biopsies positive • Have a PSA (prostate-specific antigen) less than 10

But not every eligible patient should necessarily go into an active surveillance program. Here's what to keep in mind as you're deciding.

Active Surveillance: Pros

1. Active surveillance has the least side effects. If you opt for active surveillance, you won't be undergoing therapeutic interventions (e.g. surgery, radiation) or taking medications, all of which can have unpleasant side effects. The side effects most patients typically worry about are incontinence and impotence, both of which can affect a patient's quality of life. With active surveillance, the patient won't experience these particular side effects.

A potential long-term side effect does exist, however—namely that the patient could develop metastatic cancer at some point. Active surveillance requires vigilance (more on this below). If you remove the "active" part from the equation for whatever reason, the once manageable cancer could metastasize in certain patients. 2. Active surveillance is still very much a vigorous treatment option. Some patients worry that active surveillance is akin to doing nothing, but that is false. The key word here is "active"—this is not a passive option. In order for active surveillance to work, the patient must become an engaged participant in his healthcare by participating in regular follow-ups, undergoing scheduled biopsies, and honestly discussing next steps with his physician and family.

An important note: One third of all patients who start with active surveillance will eventually need to treat the prostate cancer at some point.

Patients who choose active surveillance should do so with the mindset that they're not treating the disease today, but that they will likely have to treat it in the future. For now, they're simply delaying the side effects we mentioned above, rather than avoiding them entirely.

3. From a social standpoint, active surveillance might help reduce the overall cost of healthcare. The idea is that if you're not initiating expensive therapies at the outset, overall healthcare costs could go down in the end. Keep in mind that many older men who enter an active surveillance program might not have a long life expectancy and will die from something other than prostate cancer. And because they've opted for surveillance, they'll avoid the expense of other therapies.

Not everyone agrees with this theory, however (and it's true that costs won't necessarily go down for every individual patient—more on this below). But when considering this from a global perspective (meaning you're taking into account everyone in the world who starts out on active surveillance), overall healthcare costs could very well go down in the long run.

Active Surveillance: Cons

1. Not every patient is a good patient. As mentioned above, patients must become active participants in order for active surveillance to be an effective way to manage prostate cancer. We often see patients who are incredibly engaged during the first year or two after their initial diagnosis, but after that, they begin to miss appointments and follow-ups and/or become complacent. In other words, the "active" part falls away and it just becomes basic "surveillance."

If you or someone you love is considering active surveillance, be honest and ask yourself whether you can truly commit to an active surveillance program for the long haul. There's no shame in recognizing it's not for you, even if from a medical standpoint you are an otherwise good candidate for the program.

2. You may miss an opportunity to cure the disease. In some cases, therapeutic intervention might cure the patient's prostate cancer. However, we've seen patients so averse to interventions that they opt for active surveillance in lieu of a potential cure. So, in essence, their disease goes from potentially curable to something that now must be controlled.

And remember what we noted above: one third of all patients on active surveillance will eventually need treatment anyway because their cancer will progress to the point that they no long qualify for surveillance.

This is why patients should take a good, hard look at all options, including less invasive therapeutic treatments now available, such as radioactive seed implantation, HIFU, and cryotherapy, all of which don't typically have as toxic an effect on the body as external radiation or radical prostatectomy might have.

3. Patients on active surveillance must be willing to subject themselves to repeat biopsies. No one enjoys biopsies, but biopsies are an important element in the "active" part of surveillance.

While on active surveillance, patients should expect at least one repeat biopsy a year after the initial diagnosis. For some patients, this can be a point of decision-making; some would rather seek treatment than to subject themselves to more biopsies.

4. Depending on the patient's health insurance coverage, active surveillance could cost more. The follow-up care that's part of active surveillance involves regular office visits, MRI studies, and biopsies, all of which can affect patient deductibles and co-pays.

Greater Boston Urology: Our Thoughts on Active Surveillance

We believe that every decision should be an independent one made by the patient with information and guidance from his doctor. It's important for the patient to have a good relationship with his urologist. This way, the patient can have an honest discussion regarding what's in his best interest based on his oncologic needs, his social needs, and his individual needs, as well as his desired outcome.

For example, if the patient's desired outcome is "to be cured," then we would steer him towards the best treatment option possible to achieve that goal. If the patient's personal goal is to reduce and minimize side effects and delay or avoid unnecessary therapy, then we can help him with active surveillance, provided he's an appropriate candidate.

Here's what we want everyone to understand about active surveillance: • Going with an active surveillance program does not mean you're never going to be treated in the future. • Not every patient is a candidate for active surveillance. There's an increased perception that everyone can go on active surveillance, and that's just not the case.

At Greater Boston Urology, thanks to our integrated practice and seven convenient locations, we have the ability to provide personalized, individual attention to each patient, one at a time, and to help him and his family make the decision that's going to be best for them.

We can certainly use studies on populations and studies from leading medical journals to help guide those decisions, but we still believe the best decision comes from the honest conversations that take place between patients and their physicians.

All of our doctors strive to create strong relationships—relationships where we provide careful attention and individualized service to each and every patient.